HISPANIC YOUTH CAMP

MEDICAL CONSENT FORM
CAMPERS UNDER 17 YEARS OF AGE MUST FILL OUT
Name _____________________________________________
Birth Date __________________________________________
Date of last Tetanus Booster __________________________
Allergies to drugs/food _______________________________
SPECIAL FOOD, MEDICAL OR PERTINENT INFORMATION:
___________________________________________________
___________________________________________________
___________________________________________________
LIST OF RESTRICTIONS:
___________________________________________________
___________________________________________________
___________________________________________________
JESÚS PREPARO UNA
FOGATA PARA SUS DISCÍPULOS
LES DIJO: “VENID Y COMED...”
Father’s phone______________________________________
Father’s work phone_________________________________
Mother’s phone______________________________________
Mother’s work phone_________________________________
Emergency phone (relative/friend)_____________________
Family physician name _______________________________
Family physician address ____________________________
Family physician phone______________________________
Insurance company _________________________________
Insurance policy # __________________________________
HISPANIC YOUTH CAMP
HOSTED BY MID-AMERICA UNION
BROKEN ARROW RANCH
JULY 22-26, 2015
Authorization to Treat a Minor
I (we) the undersigned parent(s) or legal guardian of ____________________
In case of emergency, I hereby give permission to the physician selected by
the youth directors to hospitalize, secure proper treatment, for, and to order
injection, anesthesia or surgery for my child.
As parent of legal guardian of the applicant, I am in favor of him/her
attending the Hispanic Youth Congress functions and accept the conditions
named. The health history stated is correct so far as I know, and the person
herein described has permission to engage in all prescribed event activities
except as noted. In addition, I have read and understand the Emergency
Authorization statement and give my full consent to the terms found therein. Permission for photo copying of this health record is granted.
Date ______________________________________________
Parent/Guardian Signature____________________________
This section is for the notary to sign if your state requires
it.
Signed before me this _________day of___________2015
Notary______________________________________________
Date of Expiration of seal ____________________________
BROKEN ARROW RANCH
1950 Sagebrush Road, Olsburg, Kansas
FOR MORE INFORMATION
Call 402.484.3009
Email [email protected]
Mid-America Union
Youth Ministries Department
8307 Pine Lake Road
Lincoln, NE 68516
SPEAKER
JOSE CORTES, JR.
NAD ASSOCIATE
MINISTERIAL
DIRECTOR
SPEAKER
HAROLD
ALOMIA
PASTOR OF
COLLEGE VIEW
PROGRAMA
REGISTRATION INFORMATION
Miércoles, Julio 22
AGE LIMIT: 13-35
ALL CAMPERS MUST FILL OUT APPLICATION
1-5 pm
5:30 pm
7-8:00 pm
8:30-10:00 pm
Jueves, Julio 23
8 am
9 am
10 am
12:30 pm
2-5 pm
5:30 pm
7-8 pm
8:30-10 pm
Viernes, Julio 24
8 am
9 am
10 am
12:30 pm
2-5 pm 5:30 pm
8 pm
Sábado, Julio 25
9:30-11:30 am
1 pm
2-3 pm
3:30 pm
6 pm
7 pm
8 pm
9 pm
9-11:30 pm
*Actividades Recreacionales
Cena
Juegos Organizados
Asamblea General
Desayuno
Culto
*Actividades Recreacionales
Almuerzo
*Actividades Recreacionales
Cena
Juegos Organizados
Asamblea General
Desayuno
Culto
*Actividades Recreacionales
Almuerzo
*Actividades Recreacionales
Cena
Preparación /Asamblea General para el Sábado
Culto/Talleres de Ministerio
Almuerzo
Talleres de Ministerio
Tesoro Escondido
Cena
Talleres de Ministerio
Asamblea General
Puesta Del Sol
Juegos Organizados
Domingo, Julio 26
7 am
8 am
9-noon
12:30 pm
1-4 pm
Desayuno
Culto
*Actividades Recreacionales
Almuerzo Ligero
¡Despedida!
*Paseos a caballo, lanchas motorizadas,
tirolina, voleibol, fútbol, caminata,
esquí acuático, tiro con arco, escalar
pared, juegos organizados, juegos de
mesa, natación
Register through your pastor or youth leader. Before
sending registration fee, call Adela Martinez at 402.484.3009
for cabin availability.
REGISTRATION FEES
WED-SUNDAY LODGING & MEALS
CABIN RESERVATIONS:
OPEN NOW
$100.00
THURS-SUNDAY LODGING & MEALS$87.50
CABIN RESERVATIONS IF AVAILABLE:
OPEN JUNE 8
FRI-SUNDAY LODGING & MEALS $75.00
CABIN RESERVATIONS IF AVAILABLE:
OPEN JUNE 15
SABBATH-SUNDAY LODGING & MEALS$62.50
CABIN RESERVATIONS IF AVAILABLE:
OPEN JUNE 29
SABBATH ONLY
DEADLINE JULY 20
$30.00
CABINS AND TENTS
Cabins are limited. Priority is given to those staying
Wed-Sunday. After all cabins are full, you must bring
your own tent. Fees are nonrefundable.
WHAT TO BRING?
Bible
Towels
*Jeans
Flashlight
Sunscreen
Bedding/Sleeping bag
Swimsuit
Tennis shoes
Baseball glove
Bug repellent
Toiletries
Hiking shoes
Warm jacket
Soccer ball
Happy smile!
*Need for horseback riding
Traducción por el Pastor Roberto Coronado y Adela Martínez
APPLICATION
Fill in the following information with signatures, fee, and give
to your pastor or youth leader. Your pastor or youth leader
will register your application by contacting Adela Martinez
at 402.484.3009 or email [email protected]
Name _____________________________________________
Address____________________________________________
Email_______________________________________________
Cell _______________________________________________
Birth date __________________________________________
Church_____________________________________________
Pastor______________________________________________
Youth Leader________________________________________
REQUIRED SIGNATURES/INFORMATION
Camper Agreement: “I agree to abide by the rules of the
Mid-America Union Hispanic Youth/Young Adult Camp. I
understand that a violation of the camp rules may result
in immediate departure from the camp.”
Signed____________________________________________
Pastor Approval: “I approve the above applicant to be a
delegate to the Mid-America Union Hispanic Youth/Young
Adult Camp.”
Signed_____________________________________________
Print_______________________________________________
Delegates Ages 13-17
The elected Youth Leader of my church who will be
supervising me is____________________________________
Supervisor’s cell #___________________________________
CONSENT TO TREATMENT FORM ON BACK
IMPORTANT! BE SURE TO FILL OUT
IMPORTANT NOTICE: Non-registered visitors are NOT permitted and will be asked to leave the camp immediately.
SABBATH: Visitors MUST register and pay the Sabbath
fee after sunset. IF VISITORS LEAVE BEFORE PAYING,
THEIR CHURCH WILL BE BILLED.